PRIMARY LUNG ADENOCARCINOMA PRESENTING AS

DIFFUSE MULTIPLE CAVITARY NODULES IN A 37 YEAR

OLD FEMALE NEVER SMOKER: A CASE REPORT
Dawn Irvette V. Cu, MD , Maria Monica Salazar, MD
Department of Internal Medicine and Pulmonary Medicine , Chong Hua Hospital

INTRODUCTION
Diffuse multiple cavitary nodules seen on workup have a broad range of differential diagnoses. Cavities
are present in a wide variety of infectious and noninfectious processes involving the lung. The presence
of a cavity and its distribution in the lungs helps the clinician focus the diagnostic evaluation. Malignancy
rarely manifest as diffuse multiple cavitary nodules and are often not seen in the very young.

THE CASE
This is a case of a 37-year old female never smoker who
presented with non-productive cough of one month
associated with exertional dyspnea with no weight loss
nor fever. She had no family history of cancer. Chest x-ray
taken showed diffuse bilateral nodular infiltrates. Sputum
culture showed growth of Pseudomonas aeruginosa. Acid
fast staining of sputum was negative. Antibiotic therapy
done showed no improvement of symptoms. Computed
tomography (CT) scan of the chest showed multiple
cavitary nodules diffusely scattered in both lungs with tree
in bud nodular opacities. The largest nodule is situated in
the right middle lobe and measures 25mm in diameter Figure 1. Chest CT scan lung window showing
multiple cavitary nodules scattered in both lungs.
with slightly speculated margins. Transbronchial lung
biopsy, bronchial lavage, brush and wash showed lung
adenocarcinoma, positive for EGFR mutation. Metastatic
workup, including bone scan, brain magnetic resonance
imaging (MRI), and ultrasound of the whole abdomen
were negative. Patient was started on Osimertinib.

DISCUSSION
The approach to multiple cavitary lung lesions seen on Figure 2. Tumor cells consistent with
computed tomography includes differentiating between adenocarcinoma seen on biopsy.
infectious and non-infectious causes and benign or
malignant lesions. Malignant lesions of pulmonary origin, CONCLUSION
as seen in the index case comprise only 7.8% of cases.1
Cavitation only occurs in about 4% of cases of This case reports an unlikely
malignancies.2 Adenocarcinomas usually do not cavitate.3 presentation of lung adenocarcinoma
Young adults under 40 years old, of which the index case with diffuse multiple cavitary nodules in
is part, compose only 1.2% to 6.2% of cases.4 EGFR a young female never smoker. The
mutations were correlated in those with more diffuse, combination of an unusual radiographic
randomly arising lung adenocarcinomas.3 Togashi, et al appearance coupled with a history that
reported a unique pattern of lung adenocarcinoma does not highly suggest malignancy
presenting with multiple nodules with no larger than 3cm makes the diagnosis of lung
distributed in a diffuse and random manner5 similar to adenocarcinoma in the index case
that of the index case. unique.
References:
1 Giacomelli IL, Barros M, Pacini GS, Altmayer S, Zanon M, Dias AB, et al. Multiple cavitary lung lesions on CT: imaging findings to differentiate between malignant and benign etiologies.
Jornal Brasileiro de Pneumologia. 2020Jun15
2 Boitsios G, Bankier AA, Eisenberg RL. Diffuse pulmonary nodules. American Journal of Roentgenology 2010;194:5
3 Gafoor K, Patel S, Girvin F, Gupta N, Naidich D, Machnicki S, et al. Cavitary Lung Diseases. Chest. 2018Jun1;153(6):1443–65.
4 Hsu CL, Chen KY, Shih JY, et al. Advanced non-small cell lung cancer in patients aged 45 years or younger: outcomes and prognostic factors. BMC Cancer. 2012;12:241
5 Togashi Y, Masago K, Kubo T, et al. Association of diffuse, random pulmonary metastases, including miliary metastases, with epidermal growth factor receptor mutations in lung
adenocarcinoma. Cancer 2011;117:819–25.